The data are mixed regarding rates of alcohol abuse and suicide. Further research is necessary in this field. Patients who have had BS should receive ongoing psychiatric and psychological care from a multidisciplinary team as a matter of course.
Will a second surgery be needed?
Revision surgery. In 2015, about 14% of the almost 200,000 BSs performed were revisions.4 Revision surgery is indicated in BS patients with weight regain, recurrent comorbid diseases (eg, diabetes, hypertension), or complications of primary BS. Restrictive procedures have a higher revision rate than malabsorptive procedures, primarily due to a higher rate of weight regain.6,30
Because revision surgery is associated with more complications and possibly longer hospital stays than primary BS, it should be performed by a bariatric surgeon with extensive experience.30,31 Restrictive revisions are typically converted to malabsorptive procedures. Cost is a limiting factor as many patients’ insurance coverage is limited to one BS per lifetime.
Body contouring. Body contouring surgery (BCS) can improve physical and mental well-being and may be a protective factor for weight regain after bariatric surgery.32 Despite its desirability—particularly to women, adolescents, and those with large decreases in body mass index (BMI)—few patients can afford BCS since it is rarely covered by insurance.
Complications of BCS vary, but are most commonly infection and wound dehiscence. This is, in part, due to poorer wound healing in BS patients compared to those with nonsurgical massive weight loss. The cause of poor wound healing is thought to be secondary to nutritional deficiencies and the catabolic state induced by post-surgical weight loss. Recommendations for BCS include weight stability for more than one year after BS, age >16 years, excess skin causing significant functional impairment, non-smoking status, and presence of good social support.33
Bariatric surgery in adolescents is on the rise
Children in the highest body mass index quartile have more than twice the death rate of those in the lowest BMI quartile.34 Thus, it is not surprising that the rate of BS in adolescents is increasing.7 BS in this age group is successful for weight loss and improvement of comorbid conditions, with relatively low complication rates.35 Options include malabsorptive and restrictive procedures, although gastric banding has not been approved by the US Food and Drug Administration for patients under the age of 18 years.
After BS, adolescent girls should be counseled regarding the possibility of pregnancy (restoration of fertility) and appropriate contraception. Adolescent patients require nutritional supplementation after BS as indicated in TABLE 1.6,8-11
When determining which adolescents to refer for BS, we recommend the following criteria: 35-38
- failure of a minimum 6-month trial of a staged treatment approach, as recommended by Barlow et al,36 including diet, exercise, and pharmacologic treatment
- BMI ≥35 with type 2 diabetes or severe sleep apnea (apnea hypopnea index [AHI] >15)37
- BMI ≥40 with mild sleep apnea (AHI >5), hypertension, or pre-diabetes37
- Tanner stage IV or V
- at least 95% skeletal growth (for malabsorptive surgery).37 This can be determined using an estimated adult height from mid-parental height formula and assessing growth plate closure with hand radiographs for bone age
- appropriate maturity level permitting adherence
- good psychological support
- a multidisciplinary team for postoperative and long-term follow-up care.
Planning for the future: Exploring the possibility of pregnancy
Obesity is the primary cause of maternal and fetal morbidity during pregnancy. It is associated with increased rates of early miscarriage, congenital defects, macrosomia, and fetal death. Maternal risks of obesity include: gestational hypertension, gestational diabetes mellitus (GDM), and pre-eclampsia. Obese mothers also have a higher incidence of failed induction, caesarean section, and breastfeeding failure.10,39 Given that half of all BSs are performed in women of reproductive age, this population deserves special consideration.10
A recent meta-analysis by Galazis et al40 concluded that BS performed prior to pregnancy led to decreased rates of preeclampsia, GDM, large neonates, preterm birth, and neonatal intensive care unit admission. Perinatal mortality did not increase after BS. However, BS led to higher rates of maternal anemia. There was no significant difference between groups in incidence of cesarean section.
The post BS female patient should be advised to use a reliable form of contraception for a minimum of 12 to 18 months after surgery.6,10,39 Involve high-risk obstetric specialists during pregnancies. Diet should be supplemented as indicated in TABLE 1.6,8-11
CORRESPONDENCE
Amy Rothberg, MD, PhD, Domino’s Farms, Lobby G, Suite 1500, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106; amy.kreykes@gmail.com.